Correspondence to Ling Jiang; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
This study comprehensively analysed the results and associated factors of the graduation examination of standardised residency training in Zhejiang Province, China in 2020, based on a large data set.
This study did not take into account marital status, which might influence the results of the graduation examination.
This is a cross-sectional study, and it is difficult to verify the causal relationships between the associated factors and the results.
The findings of this study only reflect the situation in Zhejiang Province and cannot be generalised to the rest of China.
Introduction
Many countries have established residency training systems to standardise the quality of doctors.1 Residency training is mandatory for doctors to be qualified to practice independently.2 3 In China, standardised residency training began in 1921 when the Peking Union Medical College was founded and introduced the ‘John Hopkins model’.4 5 In 2013, seven government ministries jointly issued the ‘Guidance on the Establishment of a Standardized Residency Training System’, officially launching residency training in China.6 7 The guidelines proposed the establishment of a standardised residency training system by 2020 and stated that all new clinicians entering the medical field with undergraduate degrees and above would receive standardised residency training. Approximately 109 000 residents were enrolled in standardised residency training nationwide in 2018.8 According to the China Health Statistical Yearbook 2021, the total number of physicians reached 4.086 million by the end of 2020, of whom 38.4%, 36.2% and 5.9% had a college degree (The admission score for a medical college degree is lower than that of an undergraduate degree, and the study period is 3 years. Doctors with a college degree can apply to take the licensing examination after obtaining a license to practice as a physician assistant and working for 2 years, while those with an undergraduate degree can take the licensing examination directly. The study period for an undergraduate degree is 5 years.), an undergraduate degree and a postgraduate degree, respectively. Standardised residency training has been made mandatory, and the training period for both undergraduate and graduate students is generally 3 years.9 For those with postgraduate medical degrees and physicians who are already engaged in clinical medical practice, the training hospitals determine the specific time and content of residency training following the training standards, taking into account their clinical experience and practical ability. If they do not complete the training within the required time or fail the examination, they will need to undergo the standardised training again. The assessment of standardised residency training is divided into two parts: process assessment and graduation examination. Process assessment is a dynamic evaluation involving medical ethics, attendance, completion of training targets and learning participation. Graduation examination is a measure of the overall effect of training and includes practical skill examination and written examination. The written examination is organised by the state uniformly, using computerised question-answering methods, focusing on the assessment of examinees’ level of public basic knowledge and professional theoretical knowledge, and the practical skill examination is organised by each province.
From the beginning of 2011 to the end of 2018, a total of 42 904 residents enrolled for standardised residency training in Zhejiang Province, of whom 25 260 participated in the graduation examination and 22 530 completed their training and obtained a certificate of eligibility.10 The practical skill examination in Zhejiang Province is based on the objective structured clinical examination (OSCE) pattern and includes six modules: medical data interpretation, patient interviewing (medical history taking, physical examination), medical document writing (first course of disease record, complete medical record), clinical reasoning and decision-making, basic life support skills (cardiopulmonary resuscitation, endotracheal intubation) and specialised procedure performing. Only after passing both the written and the practical skill examinations can examinees get the certificate of eligibility. If an examinee fails to pass one of the two examinations, the result of the passed examination will remain valid and the examinee will have to pass the failed examination by a make-up examination. Moreover, if an examinee fails in any one of the six practical skill modules, they will be considered to have failed in the practical skill examination. The aim of this study is to analyse the pass rate and associated factors of the graduation examination of standardised residency training in Zhejiang Province and provide a reference basis for further improving the residency training models and assessment mechanisms.
Methods
Data source and study population
This study used data from the of graduation examination of standardised residency training in Zhejiang Province in 2020, provided by the Zhejiang Evaluation Center for Medical Service and Administration. The graduation examination was conducted in two parts: the practical skill examination was held from 4 August to 7 August 2020 and the written examination was held on 16 August 2020. The database contained information about 5555 examinees who had taken the graduation examination, including name, ID number, gender, date of birth, ethnic group, educational level, training time, whether the examinee took the examination for the first time, examinee’s organisation, types of examination taken and examination results. All 5555 examinees were included in this study.
Outcomes
According to the cut-off passing score, the original examination scores of both the practical skills and written examinations were recoded as dichotomous variables of 1=pass and 0=fail. The standardised score for passing the written examination is 400. For the practical skill examination, the cut-off passing score of medical history taking, physical examination, first course of disease record, complete medical record, clinical reasoning and decision-making, cardiopulmonary resuscitation, endotracheal intubation and specialised procedure performing was 80 out of 100, while the cut-off passing score of medical data interpretation was 60 out of 100.
Statistical analysis
Descriptive statistics were presented as frequency and percentage for the categorical variables. The Pearson χ2 test and Fisher’s exact test were used to compare pass rates by examinees’ characteristics. The multivariable logistic regression analysis was performed to identify the association between sociodemographic variables and pass rates of practical skill examination and written examination. All variables of bivariate analysis were included in the regression models. Since the practical skill examination was held before the written examination, we included the results of the practical skill examination as an independent variable in the regression model of the written examination. Adjusted ORs (AORs) with their corresponding 95% CIs from regression analysis were presented. The results of logistic regression were shown as forest plots. The two-tailed p<0.05 was considered to be statistically significant. All analyses were conducted using R V.3.6.1 for Windows.
Patient and public involvement
None.
Results
Examinees
A total of 5555 examinees registered for the graduation examination of standardised residency training in Zhejiang Province in 2020, of whom 5284 (95.1%) had taken the examination for the first time, 36 (0.7%) reregistered because they had failed the examination in previous years, 186 (3.3%) only registered for the practical skill examination and 49 (0.9%) only registered for the written examination. The majority of examinees belonged to the Han population group (98.3%), aged between 25 and 30 (77.4%), and were undergraduates (75.2%). Approximately 83.2% of the examinees had a training time of 1 year, and 80% came from hospitals and health institutions (table 1).
Table 1Examinee characteristics of the graduation examination of standardised residency training in Zhejiang Province, 2020
| Characteristics | n | % |
| Total | 5555 | 100 |
| Gender | ||
| 2640 | 47.5 | |
| 2915 | 52.5 | |
| Age | ||
| 278 | 5.0 | |
| 4300 | 77.4 | |
| 977 | 17.6 | |
| Ethnic group | ||
| 5463 | 98.3 | |
| 92 | 1.7 | |
| Educational Level | ||
| 595 | 10.7 | |
| 4176 | 75.2 | |
| 784 | 14.1 | |
| Training Time | ||
| 4621 | 83.2 | |
| 889 | 16.0 | |
| 45 | 0.8 | |
| Take the examination for the first time | ||
| 5284 | 95.1 | |
| 271 | 4.9 | |
| Examinee organisation type | ||
| 2071 | 37.3 | |
| 1204 | 21.7 | |
| 1153 | 20.8 | |
| 985 | 17.7 | |
| 142 | 2.5 |
*Those who did not find a job after graduation but directly attended the standardised residency training, or resigned to attend the standardised residency training.
Pass rates
Of the 5555 examinees, one examinee only registered for the written examination but did not take the examination, and 12 examinees only registered for the practical skill examination but did not take the examination; among the examinees who registered for both the written and practical skill examinations, 15 did not take the examinations, two only took the written examination (included in the calculation of the overall pass rate) and eight only took the practical skill examination (included in the calculation of the overall pass rate). Overall, 29 (12+15+2) examinees registered but did not show up for the practical skill examination, and 24 (1+15+8) examinees registered but did not show up for the written examination, and they were all excluded from this study. In addition, 28 (1+12+15) examinees were excluded from the calculation of the overall pass rate. In 2020, 5030 (91.8%) of the 5477 (5284+36+186–29) examinees passed the practical skill examination, 5156 (96.5%) of the 5345 (5284+36+49–24) examinees passed the written examination, and 4945 (89.5%) of the 5527(5555–28) examinees passed both the written and practical skill examinations.
Pass rates by examinee characteristics
Table 2 shows the results of the bivariate analysis of examinees’ characteristics relative to the pass rates of practical skill examination and written examination. There were significant differences in the pass rates of the two examinations in terms of gender, age, educational level, whether the examinee took the examination for the first time and the examinee’s organisation type. Female examinees had significantly higher pass rates than male examinees in the practical skill examination (93.4% vs 90.1%, p<0.001) and written examination (97.3% vs 95.5%, p<0.001). The examinees who took the graduation examination for the first time had significantly higher pass rates than those who retook the practical skill examination (92.6% vs 70.2%, p<0.001) and the written examination (97.2% vs 49.4%, p<0.001). Compared with other age groups, the youngest age group (age <25) had the highest pass rates in the practical skill examination (92.8%, p=0.002) and written examination (99.3%, p<0.001). As for the educational level, examinees with a postgraduate degree had the highest pass rates in the practical skill examination (92.3%, p=0.006) and written examination (98.9%, p<0.001). Examinees from primary healthcare institutions had the lowest pass rates in the practical skill examination (87.5%, p<0.001), and examinees from second-level hospitals had the lowest pass rates in the written examination (93.9%, p<0.001). Examinees with 3 years of training had the lowest pass rates in the practical skill examination (77.3%, p<0.001).
Table 2Bivariate analysis of the practical skill examination and written examination pass rates by examinee characteristics
| Practical skill examination (N=5477) | Written examination (N=5345) | |||||
| n | Pass rates, % | P value | n | Pass rates, % | P value | |
| Gender | ||||||
| 2600 | 90.1 | <0.001 | 2520 | 95.5 | 0.001 | |
| 2877 | 93.4 | 2825 | 97.3 | |||
| Age | ||||||
| 278 | 92.8 | 0.002 | 276 | 99.3 | <0.001 | |
| 4257 | 92.4 | 4160 | 97.2 | |||
| 942 | 89.0 | 909 | 92.2 | |||
| Ethnic group | ||||||
| 5389 | 91.9 | 0.363 | 5262 | 96.5 | 0.072* | |
| 88 | 88.6 | 83 | 92.8 | |||
| Educational Level | ||||||
| 586 | 88.4 | 0.006 | 530 | 96.6 | <0.001 | |
| 4115 | 92.2 | 4054 | 96.0 | |||
| 776 | 92.3 | 761 | 98.9 | |||
| Training time | ||||||
| 4560 | 92.6 | <0.001 | 4499 | 96.4 | 0.700 | |
| 873 | 88.4 | 802 | 97.0 | |||
| 44 | 77.3 | 44 | 97.7 | |||
| Take the exam for the first time | ||||||
| 5270 | 92.6 | <0.001 | 5264 | 97.2 | <0.001* | |
| 207 | 72.0 | 81 | 49.4 | |||
| Examinee organisation type | <0.001 | <0.001 | ||||
| 2033 | 92.6 | 2008 | 97.0 | |||
| 1184 | 91.6 | 1156 | 93.9 | |||
| 1135 | 87.5 | 1062 | 95.6 | |||
| 983 | 95.1 | 978 | 99.2 | |||
| 142 | 95.1 | 141 | 97.9 | |||
*P values were calculated by Fisher’s exact tests, other variables were compared using Pearson Χ2 tests.
Factors associated with pass rates
The results of the multivariable logistic regression analysis for the practical skill examination and written examination are shown in figure 1 and figure 2, respectively. Female examinees were more likely than males examinees to pass the practical skill examination (AOR=1.54, 95% CI 1.26 to 1.88, p<0.001) and written examination (AOR=1.65, 95% CI 1.19 to 2.30, p=0.003). Compared with those who took the examinations for the first time, examinees who retook the examinations were less likely to pass the practical skill examination (AOR=0.28, 95% CI 0.20 to 0.39, p<0.001) and written examination (AOR=0.04, 95% CI 0.03 to 0.07, p<0.001). Examinees aged 30 and above were less likely to pass the practical skill examination than those under 25 years of age (AOR=0.48, 95% CI 0.26 to 0.89, p=0.021). Compared with examinees under the age of 25, examinees aged between 25 and 30 (AOR=0.22, 95% CI 0.03 to 0.80, p=0.046) and those aged 30 and above (AOR=0.08, 95% CI 0.01 to 0.30, p=0.001) were less likely to pass the written examination. Examinees with a postgraduate degree were more likely to pass the written examination than those with a college degree (AOR=6.37, 95% CI 1.95 to 23.34, p=0.003). Examinees with 3 years (AOR=0.19, 95% CI 0.09 to 0.43, p<0.001) and 2 years (AOR=0.61, 95% CI 0.40 to 0.96, p=0.03) of training were less likely to pass the practical skill examination than those with 1 year of training. Examinees from primary healthcare institutions were less likely to pass the practical skill examination than those from tertiary hospitals (AOR=0.56, 95% CI 0.40 to 0.77, p<0.001). Compared with those from tertiary hospitals, examinees from second-level hospitals were less likely to pass the written examination (AOR=0.58, 95% CI 0.39 to 0.87, p=0.009), while examinees from colleges and universities were more likely to pass the written examination (AOR=2.87, 95% CI 1.40 to 6.65 p=0.007). Additionally, if an examinee failed the practical skill examination, they were less likely to pass the written examination (AOR=0.17, 95% CI 0.12 to 0.25, p<0.001).
Enlarge this image.Figure 1. Forest plot of the factors associated with the pass rate of practical skill examination. ‘Reference’ indicates a control group; The size of a solid circle indicates the OR value; red solid circles indicate statistically significant differences; The length of the line segment indicates the 95% CI; The dotted line in the middle indicates the invalid line with OR value equal to 1.
Enlarge this image.Figure 2. Forest plot of the factors associated with the pass rate of written examination. ‘Reference’ indicates a control group; The size of a solid triangle indicates the OR value; red solid triangles indicate statistically significant differences; The length of the line segment indicates the 95% CI; The dotted line in the middle indicates the invalid line with OR value equal to 1.
Discussion
This study showed that the pass rate of the written examination was 96.5% in 2020 in Zhejiang Province, which ranked second out of 31 provinces nationwide, and it basically remained unchanged from the pass rate in 2019 (95.4%). The written examination pass rate for 2019 had increased by 2.55 percentage points compared with the 2018 pass rate. The slower growth of the pass rate may be related to the following aspects: first, the pass rate of the written examination is already relatively high and there is little room for further improvement; second, many residents are involved in the prevention and control of the COVID-19 pandemic and have insufficient time to study theoretical knowledge; third, a study showed that the proportion of residents suffering from anxiety and depression symptoms increased during the COVID-19 pandemic, which may have affected their performance in the written examination.11 The pass rate of the practical skill examination was 91.8%, an increase of 1.5 percentage points over 2019 (90.3%). Before 2020, the practical skill examination was conducted with standardised patients and patients, but due to the COVID-19 pandemic, the examination mode was switched to simulation models for most disciplines in 2020, which made the examination less difficult as examinees did not have to face a complex clinical environment. A scoping review showed that many alternative teaching methods such as video teleconferencing, virtual ground rounds and virtual case conferences were used to conduct residency education during the COVID-19 pandemic. However, the effectiveness of these new methods of teaching has not been well examined.12 Additionally, the pass rate of the practical skill examination was lower than that of the written examination, which may be related to several factors: first, the training time for practical skills is less than the learning time for theoretical knowledge; second, the practical skill examination mainly tests examinees’ clinical thinking, case writing, skills operation and other comprehensive abilities and is more difficult than the written examination; third, practical skills training is influenced by many environmental factors, such as the level of the training hospital, the level of clinical teachers and teaching and training methods.13–15 Therefore, clinical practice skills should always be a top priority of training.16 Since the content of the practical skill examination is not uniform across provinces, it is not appropriate to compare pass rates.
This study further found that female examinees had higher pass rates than male examinees in both practical skills and written examinations. However, some previous studies did not find differences in the evaluation results by gender.17–19 Examinees aged 30 and above had the lowest pass rates in both practical skill and written examinations, which may be because older examinees may have had some clinical work experience and developed certain personal work habits before their standardised training and, therefore, have difficulty adapting to the new training requirements. Examinees with postgraduate degrees were more likely to pass the written examination than examinees with college degrees, a result consistent with the findings of a previous study in Guangdong Province.20 Several other studies have shown that examinees with postgraduate degrees have higher pass rates than examinees with undergraduate degrees in both practical skills and written examinations.21 This may be because postgraduate degree holders have more solid theoretical knowledge and more opportunities for clinical training. Additionally, postgraduate candidates are more likely to come from higher level universities and receive academic guidance from mentors. Resident research productivity has been shown to be positively correlated with the number of faculty members, the educational background of faculty members and programme funding.22 23 Since the content of the written examination is nationally standardised, it is worth further exploration to achieve homogeneous training requirements for examinees with different qualifications. Examinees with 3 years of training had a lower pass rate than those with 1 year of training in the practical skill examination. This may be because the examinees with 1 year of training are those who have worked for many years and have extensive clinical practice experience, and their training time is accordingly reduced. Furthermore, examinees who took both the practical skills and written examinations for the first time had significantly higher pass rates than those who retook the examinations. According to a study, competency in technical skills is associated with a higher percentage of cognitive task scores.24 The present study found that if an examinee did not pass the practical skill examination at the outset, they would be less likely to pass the written examination. This may be because the new policy has changed the examination pattern from two times a year to once a year, and if examinees fail the examination, they will not be able to obtain their degree within a year, which will affect their employment and application for doctoral degrees; therefore, examinees who retake the examination may be more nervous and anxious.
Examinees from primary healthcare institutions were less likely to pass the practical skill examination than those from tertiary hospitals. This may be partly because advanced medical equipment and highly qualified doctors were mainly concentrated in tertiary hospitals,25–27 and partly because most examinees from primary healthcare institutions are assistant general practitioners with only 2 years of training and have insufficient clinical practice experience. Examinees from colleges and universities had a higher pass rate in the written examination compared with those from tertiary hospitals. This is mainly because most of the examinees from colleges and universities are full-time students who are about to graduate, and their theoretical knowledge has been consolidated and strengthened after 3 years of study.
The main objective of residency training in China is to standardise and homogenise physician training.28 29 However, the heterogeneity of physicians in terms of age, region, marital status, educational level and type of institution was associated with the residency training activities and examination results.29 Therefore, there is a need for differentiated and tiered training based on different competencies and specialties. Additionally, diverse teaching and evaluation methods should be used, such as competency-based learning, Plan-Do-Check-Act model, and mini clinical evaluation exercise (mini-CEX)/OSCE combined evaluation system.30–33
This study has several limitations. First, the study only analysed the pass rates of the written and practical skill examinations and did not compare the performances of the different modules of the practical skill examination. Second, some studies have shown that marital status has a significant impact on resident performance.28 34 However, this study did not include marital status as an independent variable. Third, this study only analysed data for the year 2020 and no time series analysis was conducted; thus, the reliability of the findings is somewhat affected. Finally, the results of this study cannot be compared internationally due to the differences in the contents and forms of standardised residency training examinations in different countries.
Conclusions
The pass rate of the graduation examination of standardised residency training in Zhejiang Province was high, with the written examination having a higher pass rate compared with the practical skill examination. Some demographic characteristics of examinees and the level of training hospitals are important factors associated with the pass rates of the graduation examination. Diversified and differentiated training should be provided for examinees with different characteristics.
Data availability statement
Data are available upon reasonable request.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
This is an observational study based on an administrative database and does not involve any patients. The need for ethical approval was waived by the local Ethics Committee of Hangzhou Medical College.
Contributors QG and LJ were responsible for the study conception and design. QG, ZX and LJ analysed and interpreted the results. RL and XQ conducted the literature search. QG drafted the manuscript. LJ acts as the guarantor. All authors reviewed and approved the final version of the manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
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Details
; Li, Ruoqi 2 ; Xia, Zhijun 3 ; Qu, Xianguo 2 ; Jiang, Ling 4 1 School of Public Health, Hangzhou Medical College, Hangzhou, China
2 The Fourth Clinical Medical College (Hangzhou First People's Hospital), Zhejiang Chinese Medical University, Hangzhou, China
3 Office of Academic Research, Hangzhou Medical College, Hangzhou, China
4 Department of Education and Training, Zhejiang Evaluation Center for Medical Service and Administration, Hangzhou, China